Amis and Fistula in Ano. 



M. D.. 



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FISSURE OF THE ANUS 



AND 



FISTULA IN ANO. 



LEWIS H. ADLER, Jr., M.D., 

Instructor in Diseases of the Rectum, in the Philadelphia Poly- 
clinic and College for Graduates in Medicine. 



NOV 19 1892 



-vO 




1892. 
GEORGE S. DAVIS, 

DETROIT, MICH 



^v 



Copyrighted by 

GEORGE S. DAVIS. 

1892. 



TABLE OF CONTENTS. 



FIRST PART.— ANAL FISSURE, OR IRRITABLE 
ULCER OF THE RECTUM. 

Page 
Chapter I. 

Definition — Location — Age and Sex Affected — Etiology. . I 

Chapter II. 
Symptomatology — Physical Exploration — Diagnosis — 

Prognosis 1 1 

Chapter III. 
Treatment, Palliative and Operative 22 

SECOND PART.— FISTULA IN ANO. 

Chapter I. 
Relative Frequency — Age and Sex Affected — Etiology — 

Classification 34 

Chapter II. 
Symptomatology — Physical Exploration — Diagnosis — 

Prognosis 44 

Chapter III. 
The Palliative Treatment 53 

Chapter IV. 
The Operative Treatment 60 



PREFACE. 



In the following pages I have endeavored to give a con- 
cise yet thorough account of the two affections Fissure of 
the Anus and Fistula in Ano, in respect to their etiology, 
symptomatology, diagnosis, and treatment. It has not been 
my object to write upon rectal fistulse in general. 

While the two subjects treated in this volume have been 
ably written on at various times and by different authorities, 
it is undeniable that no organ of the body is more neglected 
by both the laity and the profession than is the rectum. 

The neglect upon the part of the laity is largely attrib- 
utable to carelessness in regard to regularity of habit and to 
want of cleanliness in this portion of the body. This neglect 
is the prime factor in the causation of many of the rectal 
maladies frequently encountered by the specialist. Further- 
more, patients suffering from rectal diseases, especially 
women, often from a false sense of modesty defer their visit 
to a physician as long as possible, allowing their trouble to 
proceed from bad to worse, and when their suffering finally 
becomes almost unbearable and a doctor is consulted they 
refuse to allow him to make a rectal examination; in this 
way error in diagnosis occurs, and consequently relief is not 
obtained. The use of improper paper for toilet purposes 
often occasions the production of rectal diseases. 

The profession as a body find other fields of labor more 
inviting than the study and treatment of rectal diseases, the 
diagnosis of which to be complete and satisfactory must in 
every case be based upon an ocular and thorough digital 
examination. As a result of this unattractiveness, even 
amounting to repulsiveness, to the general practitioner, 
most of the affections of the lower bowel are treated by him 



VI 

as " piles," the diagnosis being usually made by the patient, 
and accepted by the physician without question or personal 
examination. Such being the case, it is no wonder that 
when the surgeon prescribes equal parts of ung. acid, tannici 
et ung. belladonna, or a similar salve, to every patient com- 
plaining of rectal trouble, a cure does not often result. 

A knowledge of these facts has led me to hope that a 
brochure upon the subjects herein treated might excite a 
deeper professional interest in rectal maladies if issued as 
a volume of the Physician's Leisure Library Series, which 
by its moderate price permits of a wide circulation. 

I desire to express my obligations to the publisher, Mr. 
George S. Davis, for the attractive style in which the work 
has been issued, and to Dr. B. W. Palmer, of Detroit, Mich., 
for valuable suggestions while the work was passing through 
the press; also to my friend Dr. G. G. Davis, of Philadelphia, 
for the original drawings furnished, from which a number 
of the illustrations have been executed, and to Messrs. Chas. 
Lentz & Sons, surgical cutlers of Philadelphia, for the use of 
various cuts of instruments. 

Lewis H. Adler, Jr. 
1610 Arch Street, Philadelphia, Pa. 



Part I —Irritable Ulcer of the Rectum, 
or Fissure of the Anus. 



CHAPTER I. 

DEFINITION— LOCATION— AGE AND SEX AF- 
FECTED—ETIOLOGY. 

Fissure. — The domain of surgery includes few 
diseases which produce such intense suffering to the 
patient as does the affection under consideration, and 
none in which proper treatment is followed by more 
prompt relief and more certain ultimate success. 

Fissure, although so simple in extent and 
character and so readily curable, exercises a most 
potent influence in undermining the patient's health 
and strength, the constant pain and irritation to the 
nervous system being more than the majority of per- 
sons can endure. 

Definition. — We may define a fissure, or irri- 
table ulcer of the rectum, as a superficial breach of 
the mucous membrane in the anal region, of a highly 
sensitive nature, giving rise to spasmodic contraction 

and paroxysmal pain of a peculiar character. Ac- 

i jjj 



cording to Bodenhamer,* its shape may be linear, ob- 
long, or circular. 

Location. — Its position is usually just within the 
verge of the anus, beginning at the muco-cutaneous 
junction or Hilton's line, and extending upward 
toward the rectum for a distance seldom exceeding 
half an inch. It may occupy any portion of the cir- 
cumference of the anal region, but its usual site is at 
its posterior or coccygeal side. 

Multiple Character. — Although this lesion is 
usually solitary, we sometimes find it multiple, especi- 
ally when it is of syphilitic origin. 

Age and Sex Affected. — Anal fissure is a dis- 
ease of adult life, and is said to be more common 
among women than among men. Very young chil- 
dren, however, are not exempt, as many reported 
cases show. The late Dr. D. Hayes Agnewf men- 
tions having seen it occur in infants not over two 
months old. Dr. A. Jacobi I is of the opinion that 
this affection is a more common one than is generally 
supposed, and believes that many of the fretful chil- 
dren who sleep badly and cry constantly, and often 
present symptoms simulating those of vesical calculus, 
suffer from fissure of the anus. He quotes Kjellberg, 
who at the Dispensary at Stockholm among 9098 
children found 128 cases of fissure of the anus, of 



* " Anal Fissure," 1868, p. 45. 

f " Principles and Practice of Surgery," vol. i, p, 416. 

X iv Intestinal Diseases of Children," p. 295. 



which number 60 were boys and 68 were girls; the 
majority were less than one year old, and in 73 cases 
the age was less than four months. 

Etiology.— The explanation of the very intense 
pain by which this disease is characterized is to be 
found upon study of the structural arrangement of 
the termination of the bowel, with especial attention 
to the nerve-supply of the part. Therefore it will be 
in order to review at this point the more important 
anatomical features of the lower portion of the 
rectum. 

The outlet of the intestine is closed by two 
sphincter muscles, the external being immediately 
beneath the skin surrounding the margin of the anus. 
It is elliptical in form, about half an inch in breadth 
on each side of the anus, and is attached posteriorly 
by a small tendon to the tip and back of the coccyx; 
anteriorly it becomes blended with the transverse 
and bulbo-cavernosus muscles at the central point of 
the perineum. The internal sphincter consists of the 
normal circular fibers of the rectum, considerably in- 
creased in number; its thickness is about two lines, 
and its vertical measurement from half an inch to an 
inch. It is situated, immediately above and partly 
within the deeper portion of the external sphincter, 
being separated from it by a layer of fatty connective 
tissue. 

These muscles — the two sphincters — are separated 
on the outer side by the attachment of the levator 



_ 4 — 

ani, some of the fibers of which are internally con- 
nected with the external sphincter; on the inner side 
the muscles are in contact, the line of union corre- 
sponding accurately with the junction of the skin and 
the mucous membrane. In most cases this junction 
of the sphincters is marked by a line of condensed 
connective tissue.* This line is known as " Hilton's 
white line." 

Hilton has pointed out an important anatomical 
fact in connection with this line — to wit, that it is the 
point of exit of the nerves, principally branches of 
the pudic, which descend between the two sphincter 
muscles, becoming superficial in this situation, and 
are there distributed to the papillae and mucous mem- 
brane of the anus (Fig. i). 

These nerves are very numerous, which accounts 
not only for the extreme sensitiveness of the part, 
but also, as stated by Andrews, f for its very abundant 
reflex communications with other organs. They play 
a very important part in the etiology of irritable 
ulcers. The exposure of one of their filaments, either 
in the floor or at the edge of the ulcer, is an essential 
condition of its existence. J 

The upper portion of the rectum possesses very 



* Andrews, " Rectal and Anal Surgery," Chicago, i£ 
p. 69. 

f Op. cif., p. 69. 

X Ball, "The Rectum and Anus," Philadelphia, iS 
pp. 128-129. 



little sensibility, as the chief nerve-supply of the 
•organ is at its termination and around the anus; 
hence it is that such grave diseases as cancer or 
ulceration may exist in the higher parts of the bowel 
and not manifest their presence by pain. 




Fig. i. — Nervous Supply of the Anus (Hilton), a, mucous 
membrane of the rectum; b, skin near the anus; c, external 
sphincter muscle; d, internal sphincter muscle; e, line of 
separation of the two sphincters; /, the overlying white line 
marking the junction of the two sphincters; g y nerve supply- 
ing the skin near the anus, which it reaches by passing first 
externally to the rectum and then through the interval be- 
tween the two sphincters; /z, flap of mucous membrane and 
skin reflected back. 

Andrews* directs attention to Hilton's diagram 



b. cit. y pp. 69-70. 



— 6 — 

(Fig. 2), as showing that impressions from a fissure 
are carried to that part of the cord which supplies the 



PUDtC. 




Fig. 2. — Diagram of the Nervous Relations of Irritable 
Ulcer of the Anus (Hilton), a, ulcer on sphincter ani; b, fila- 
ments of two nerves are exposed on the ulcer, the one a nerve 
of sensation, the other of motion, both attached to the spinal 
cord, thus constituting an excito-motor apparatus; c f levator 
ani muscle; d, transversus perinsei muscle. 



pudic nerves and the iliolumbar, lumbar, and sciatics, 
which include the motor supply of the external 
sphincters as well as of the bladder and the lower 
extremities. 

From these general considerations we can under- 
stand why reflex spasm of the sphincter is so constant 
and important a sign of this malady, and how other 
and more general reflexes are to be accounted for, — 
such as symptoms of bladder and urethral diseases, 
radiating pains, etc. 

We also find in the nervous mechanism of the 
part an explanation of the predisposing causes, im- 
portant symptoms, and pathology of this peculiar 
affection. 

As to the immediate origin of this lesion, it may 
be said to arise from a variety of causes, such as 
atony of the rectum, or other conditions leading to 
constipated habits. In these cases the bowel be- 
comes impacted with hardened feces, which when 
discharged overstretch the delicate mucous mem- 
brane, and thus, either by irritation or by direct 
abrasion, the ulcer is formed.* 



* Bodendamer {pp. cit., p. 58) calls attention to a fact of 
some importance as bearing upon this point — to wit, that in 
some cases of constipation, while the diaphragm and other 
abdominal muscles act with considerable energy, the anal 
sphincters remain more or less contracted, and yield but 
slowly, so that the indurated feces contuse and abrade the 
surface of one or more points of the mucous membrane, 
which abrasions, if they do not heal, lay the foundation of 
the disease. 



— 8 — 

In consequence of spasmodic or organic contrac- 
tion of the external sphincter ani, fecal matter or 
some other foreign body lodges in the fossa between 
the two anal sphincters, and by its long-continued 
presence in this pent-up situation becomes highly 
irritating and gives rise to an obstinate fissure.* 

Anal fissure sometimes results from the excoria- 
tions produced by vitiated and acrid discharges, such 
as occur in dysentery, chronic diarrhoea, cholera, 
leucorrhcea, etc. Hemorrhoids are frequently a pre- 
disposing cause and a complication of this affection. f 
They narrow the outlet of the bowel, and through the 
successive inflammatory attacks to which they are 
subject the neighboring tissue loses its elasticity, is 
rendered brittle, and is easily lacerated. 

Polypi are not uncommon causes of this lesion. J 
The polypus is usually situated at the upper or inter- 
nal end of the fissure, but it may be on the opposite 
side of the rectum, as in several cases coming under 
the author's observation. 

Allingham § states that ulcer of the rectum may 



* Instances of this condition as the cause of anal fissures 
are mentioned by T. B. Curling in his '* Observations on the 
Diseases of the Rectum," second edition, London, 1855. 

f T. J. Ashton, " Diseases of the Rectum," second Ameri- 
can from the fourth English edition, 1865, p. 46. 

:f Allingham, 4< Diseases of the Rectum," fifth edition, 
London, 1888, p. 208. 

§ Op. cit. y p. 209. 



result from a congenital narrowness of the anal orifice, 
being then usually seen in children; or it may be 
caused by an hypertrophied condition of the sphinc- 
ters, which has arisen from severe constipation or 
some rectal affection. 

Anal fissure is sometimes produced by a super- 
ficial excoriation or ulceration of the outlet of the 
bowel, analogous to that so frequently observed upon 
the inside of the lips, the tongue, and other parts of 
the mouth. Bodenhamer* mentions having seen sev- 
eral severe cases of this disease produced by a kind of 
aphthous ulceration in nursing mothers, and one in a 
child. They were attended with extreme burning 
pain and more or less anal spasm. He also states 
that in these cases the ulcerations of the anus were 
contemporaneous with similar ulcerations of the 
mouth; their coexistence and the exact similarity of 
their appearance left little doubt as to their identity. 

Harrison Crippsf states that a source from which 
these ulcers sometimes take their origin is a little 
marginal abscess which has led to the destruction 
of the portion of the muco-cutaneous surface lying 
over it. 

The anus is liable to a species of chapping resem- 
bling that of the lips in winter, which sometimes results 
in extremely painful fissures. Such a condition is 



* Op. cit. y p. 5q. 

f " Diseases of the Rectum and Anus," second edition, 
London, 1890, p. 185. 



— JO — 

supposed to be induced by the influence of a dry 
atmosphere or by some slight disturbance in the gen- 
eral health, rendering the parts friable and liable to 
crack from the slightest violence. 

Fissure is sometimes of syphilitic origin. Finally, 
it may be due to mechanical injuries, such as uterine 
displacement, the severe straining efforts made in 
parturition, the careless use of the enema syringe, 
the awkward employment of instruments by the sur- 
geon in the diagnosis and treatment of rectal diseases, 
etc. 



CHAPTER II. 

SYMPTOMATOLOGY— PHYSICAL EXPLORATION 
—DIAGNOSIS— PROGNOSIS. 

Symptoms. — The symptoms in the early stage of 
this disease are not usually severe, and are generally 
experienced during defecation, when at some point or 
other there will be an uneasy sensation, consisting 
of an itching, pricking, slight smarting, or a feeling 
of heat about the circumference of the anus. As 
the disease progresses, the discomfort attending the 
movements of the bowel is greatly augmented, and at 
a variable period of time gives place to a severe pain, 
of a burning or lancinating character, which is fol- 
lowed by throbbing and excruciating aching, at- 
tended by violent spasmodic contraction of the 
sphincter muscles, continuing from half an hour to 
several hours. 

From reflex irritation, pains are often experienced 
in other parts, simulating sciatica or rheumatism; the 
urinary organs, as has already been mentioned, are 
liable to be sympathetically deranged, causing atten- 
tion to be diverted from the real seat of the disease. 

The ulcer being fully established, the suffering 
usually comes on with intensity shortly after the 
actual passage of the motion, and frequently it lasts 
for many hours, completely incapacitating the patient 



12 

for work while it continues. I have known persons 
affected with this malady who for hours were obliged 
to maintain one position, or to assume the recumbent 
posture, for fear that the slightest movement would 
aggravate the pain. 

After an indefinite period the pain subsides or 
entirely disappears, the patient feeling fairly comfort- 
able, or even perfectly well, and to all outward ap- 
pearance he would continue so were it not for the 
knowledge that the subsequent passage of fecal 
matter will bring with it a recurrence of agony. In 
•consequence of this dread, the act of defecation is 
postponed as long as possible, with the result that 
when the evacuation does take place the pain is 
greatly increased. 

The feces, when solid, will be passed streaked 
with purulent matter, — possibly also with blood, — and 
when more soft will be figured and of small size; 
sometimes they are flattened and tape-like, due to the 
incomplete relaxation of the sphincters during defeca- 
tion. Not infrequently the appearance of such a 
stool leads the inexperienced to make a diagnosis of 
stricture of the rectum. In this connection it may be 
well to state that a fissure is sometimes found associ- 
ated with a stricture, which latter is due to a con- 
genital contracted state of the anus. Serremone, 
quoted by Ball,* believes that the stricture is the 



'Op. cit., p 132. 



— i3 — 
cause and not the result of the fissure, the narrow 
outlet being more liable to injury from over-stretching. 

When a fissure is of long duration, the constitu- 
tion becomes greatly impaired as a result of the con- 
stant pain, the constipation, and the frequent resort to 
narcotics, and the patient is liable to fall into a state 
of melancholy and extreme nervous irritability; the 
countenance, expressive of pain, grows care-worn 
and sallow; the appetite is poor; and there is more or 
less emaciation, associated with the general appearance 
of a person suffering from serious organic disease. 

Flatulence is another annoying symptom that 
generally attends severe cases of anal fissure.* It is^ 
not only troublesome, but also painful, the disengage- 
ment of gas being almost certain to bring on a 
paroxysm of pain. 

Such are the rational symptoms of anal fissure. 
If, then, a patient comes to a physician, complaining 
of severe pain lasting for some time after defecation,, 
the presumption is strong that a fissure exists, since 
no other rectal disease produces this characteristic 
distress. But in this as in all other affections of the 
inferior extremity of the intestinal tract we must sup- 
plement our investigation by an actual exploration of 
the parts, in order to determine the true character of 
the trouble and to exclude the presence of coexisting 
lesions. 



' Bodenhamer, op. cit., p. 81. 



— 14 — 

Ocular and Digital Examination. — Previous 
to making the rectal examination, the bowels should 
be thoroughly emptied by an enema, — the subsequent 
pain and anal spasm being prevented by a preliminary 
local application of a four-per-cent. solution of the 
hydrochlorate of cocaine to the mucous membrane of 
the anus, the drug being applied on a pledget of cot- 
ton and left in situ for five or ten minutes. Care must 
be exercised not to use the solution too freely, as 
otherwise toxic symptoms are apt to ensue when the 
drug is employed in this region. The rich lymphatic 
and vascular supply of the part probably accounts for 
this fact. 




Fig. 3. — Head Mirror. 
The rectum and the bladder being completely 
evacuated, the patient should be placed on the side in 
a good light, with the knees drawn up and one hand 
supporting the"uppermost buttock. To condense the 
light on the parts to be examined the head mirror 
may be employed (Fig. 3). 



— is — 

Upon inspection, the first thing that attracts our 
notice, frequently, is a red, somewhat edematous 
prominence (Fig. 4) close to the verge of the anus, 
looking not unlike a small hemorrhoid. This excres- 
cence has been termed the " sentinel pile." Upon 
placing a finger on each side of the tumor and press- 
ing down and out, as recommended by Bodenhamer,* 
the fissure will be seen. 




Fig. 4. — Anal Fissure associated with the so-called "sen- 
tinel pile " (Bodenhamer). 

An important point, to which Bodenhamer calls 
* Op. cit. y p. 92, 



— i6 — 

attention, is the external appearance of the anus itself, 
which in these cases is usually in a highly contracted 
state and more or less infundibuliform; the observer 
being struck by the very considerable depth to which 
the anus is retracted, and its unnatural look. 

The fissure is sometimes difficult to find, and 
must be searched for in the folds of the anus. This 
can be accomplished by drawing the mucous mem- 
brane away on each side, by which means we shall 
usually be able to see just within the orifice an elon- 
gated, club-shaped ulcer, the floor of which may be 
very red and inflamed, or, if the disease is of long 
standing, of a grayish color, with the edges well 
defined and indurated. Sometimes the ulcer is quite 
superficial, while in other instances it extends com- 
pletely through the muco-cutaneous surface, exposing 
the subjacent muscular coat. Cripps* states that 
these ulcers are sometimes undermined, so that a 
probe may be passed for a short distance beneath 
them, while occasionally a little fi-stulous channel will 
run some distance up the anus. 

A fact to which special attention should be 
directed here is that small ulcerations may exist in 
the sinuses of Morgagni. Kelseyf and VanceJ have 
met with such cases, the ulceration being completely 



* Op. cit., p. 187. 

f " Diseases of the Rectum and Anus," third edition,. 
New York, 1890, p. 294. 

:f Medical and Surgical Reporter, August 14, 1880. 



— 17 — 
hidden from sight, and detectable only by the sharp 
pain caused by the introduction of a small bent probe. 
This condition is no doubt a rare one, but is none the 
less important on this account, for its situation is such 
that it may be readily overlooked. 

The next step in the examination of a case of 
fissure is the introductiorfof the finger into the rec- 
tum,* and it should be conducted in the following 
manner, f If the lesion be situated dorsally, pressure 
should be made by the finger toward the perineum, 
thus avoiding the fissure and rendering the introduc- 
tion of the digit as painless as possible. If the fissure 
be situated anteriorly or laterally, the finger should 
be pressed toward the opposite side of the bowel. 

In cases of fissure the speculum ani is seldom re- 
quired by those accustomed to making rectal exami- 
nations. In the majority of instances the possession 
of the tactus eruditus — education of the sense of touch 
— will enable the surgeon to form a correct diagnosis 
without the aid of this instrument, and thus save the 



*In some cases of fissure the irritable condition of the 
sphincter will cause such contraction of the anus when an 
examination is attempted that it will be impossible for the 
surgeon to pass his finger into the rectum without etheriza- 
tion of the patient. In these instances it is best to advise 
the patient to submit, to such operative measures as may be 
deemed necessary at the same time that the examination is 
made under ether. 

f Allingham, op. cit., p. 212. 

2 jjj 



— 18 — 

patient much pain. If a speculum should be re- 
quired, the instrument of Aloe (Fig. 5) or of Sims 
(Fig. 6) may be employed. 

It is not an uncommon occurrence, according to 




Fig. 5. — Aloe's Speculum. 




Fig. 6.— Sims' Speculum (detachable handle). 



— i 9 — 

Allingham,* to find a polypus associated with fissure, 
it being situated at the upper end of the ulcer, or 
lying against it on the opposite side of the wall of the 
rectum. I have met with several such instances. If the 
polypus be undiscovered, treatment of the fissure will 
prove useless, for it will not heal until the polypoid 
growth is removed. In searching for a polypus, it is 
important to remember that the investigation should 
be conducted by passing the finger from above 
downward, as otherwise the tumor may be pushed 
up out of reach, the pedicle in these cases often being 
of considerable length. 

Diagnosis. — The manifestations of this disease 
are so characteristic of the lesion that it seems almost 
impossible for an error to be made in its diagnosis. 
The peculiar nature of the pain, the time of its occur- 
rence (either during or some time after an evacuation 
of the bowels), its continued increase until it becomes 
almost unbearable, and its gradual decline and entire 
subsidence until the next evacuation, are symptoms 
clearly pointing to fissure, and in most instances 
should be sufficient evidence to establish a diagnosis; 
yet in a number of well-authenticated cases mistakes 
have been made, and patients suffering from this 
disease have been treated for neuralgia, uterine or 
vesical trouble, stricture, and even hemorrhoids. 

Anal fissure is very readily distinguished from 



Op. a't., p. 212. 



neuralgia by the absence in the latter of any breach of 
surface or of any other disease of the mucous mem- 
brane of the rectum; by the entire want of connection 
between the pain and the alvine evacuations; and by 
the constant suffering. In neuralgia the pain caused 
by pressure with the finger in the anus is not confined 
to one spot, as it is in fissure, but all portions of the 
bowel are alike tender. It is true that the morbid 
sensibility of the rectum and anus caused by a fissure 
and that caused by neuralgia are often so intimately 
blended that it is sometimes no easy matter to dis- 
tinguish between them; nothing but the detection 
itself, in some cases, of the fissure, which can always 
be discovered by a thorough examination, will clear 
up the diagnosis.* 

The symptoms of anal fissure often simulate so 
closely those of uterine disease and bladder affections 
that the surgeon is led astray and overlooks the real 
seat and true nature of the malady. Occasionally 
the spasmodic condition of the sphincter in these 
cases simulates the symptoms of stricture; but a thor- 
ough examination will dispel all uncertainty by re- 
vealing the presence of the ulcer. 

Frequently uterine trouble or hemorrhoids are 
found associated with the fissure, and in this event 
the case is treated for either one or the other of the 
first two complaints, the presence of the other lesion 



' Bodenhamer, op. cit., p. ioo. 



21 

being unsuspected and consequently neglected. In 
all such instances a careful inspection of all the parts 
concerned will at once remove all errors in diagnosis 
and dispel all doubts. 

In children, the fact must always be borne in 
mind that fissures and other erosions about the anal 
orifice may be due to the scratching induced by the 
irritation of pin-worms. 

Course and Prognosis. — Anal fissure is not an 
immediately dangerous disease; nor can it be said that 
it has any tendency toward recovery if let alone. 
An indefinite time may elapse without any other 
change than the gradual wearing down of the pa- 
tient's vitality from continued suffering and nervous 
strain. With proper treatment, however, this disease 
can be promptly cured, and practically without risk, 
the operation usually practiced being one of the sim- 
plest of surgical procedures. 



CHAPTER III. 

TREATMENT, PALLIATIVE AND OPERATIVE. 

It is highly important to the success of any plan 
of treatment directed toward the cure of anal fissure, 
that attention be paid to the condition of the bowels. 
Regularity of habit should be established, and the 
evacuations rendered semi-fluid — as figured or hard 
stools generally aggravate the symptoms. 

To accomplish these purposes, enemata or mild 
aperients should be employed, and the diet must be 
regulated, the use of bland and unirritating food being 
enjoined. 

All drastic purges should be avoided, as they are 
more or less irritating to the extremity of the rectum. 

In order to establish a daily evacuation of the 
bowels and to render the movement as painless as 
possible, I am in the habit of ordering an enema of 
warm water, or one of rich flaxseed tea, say from half 
a pint to a pint, to be administered every evening; 
preference being given to the night-time, as then the 
patient can assume the recumbent posture, which, 
combined with the rest, affords the most relief from 
subsequent pain. 

If the first enema should prove ineffective, it 
should be repeated in half an hour. In order to re- 
lieve the pain and spasm of the sphincters attending 
the evacuation, it is well to use a suppository about 



— 2 3 — 
half an hour before the enema is employed, consist- 
ing of: 

3 Ext. belladonnas gr. % ad J£. 

Cocain. hydrochloratis gr. % ad l / 2 . 

Ol. theobromae gr. x. 

Misce, et fiat suppositoria j. 

Or an ointment of extract of conium may be used, as 
recommended by Harrison Cripps : * 

5 Ext. conii 3 ij. 

Olei ricini 3 ii j - 

Ung. lanolini ad § ij. 

A small quantity of this ointment should be 
smeared on the part five minutes before expecting 
a motion, and again after the motion has passed. 

All ointments used in the treatment of rectal dis- 
ease may be applied by means of a hard-rubber pipe 
(Fig. 7). 




Fig. 7. — Hard-rubber Ointment-Applicator. 

The various methods of treating anal fissure may 
be divided, for the sake of convenience, into the 
palliative and the operative. 



* Op. cit., p. 189. 



— 2 4 — , 

Palliative Measures. — Palliative treatment 
will meet with success in a considerable proportion of 
cases, especially when there is no great hypertrophy 
of the sphincter muscles. Allingham* states that the 
curability of this lesion does not depend upon the 
length of time during which it has existed, but rather 
upon the pathological changes it has wrought. He 
asserts that he has cured fissures of months' standing 
by means of local applications, where the ulcers were 
uncomplicated with polypi or hemorrhoids, and where 
there was not very marked spasm or thickening of the 
sphincters. 

It is essential to the success of the treatment 
of fissure, especially by local applications, that rigid 
cleanliness of the parts be maintained; for this pur- 
pose the anus and the adjacent portions of the body 
should be carefully sponged night and morning and 
after each stool with hot or cold water, the tempera- 
ture being regulated to suit the patient's comfort. 

An excellent instrument for irrigating the rectum 
is the one devised by Dr. Edward Martin, of Phila- 
delphia (Fig. 8). I have also employed Bodenhamer's 
instrument for this purpose (Fig. 9). 

In applying the various local remedies it is neces- 
sary first to expose the ulcer to view, and to anaes- 
thetize its surface with a four-per-cent. solution of 
hydrochlorate of cocaine, well brushed in with a 

* Op. cit., p. 215. 



— 25 — 
camel's-hair pencil. The application of the cocaine 
may have to be repeated once or twice, at intervals 
of three or four minutes, in order to obtain the desired 
anaesthetic effect. 




Fig. 8. — Martin's Rectal Irrigator. 




Fig. 9. — Bodenhamer's Irrigator. 

If any ointment has been used about the fissure, 
the anus should be subjected to a hot-water douche 
before using the cocaine, as cocaine will not exert its 
anaesthetic influence on a greasy surface.* For this 
purpose Martin's irrigator (Fig. 8) answers admira- 
bly. The parts should subsequently be dried thor- 
oughly with cotton or a sponge. A convenient 
sponge or cotton mop holder is shown in Fig. 10. 




Fig. 10. — Rectal Sponge-Mop Holder. 



*W. P. Agnew, M.D., "Diagnosis and Treatment of 
Rectal Diseases," second edition, i8gr, p. 97. 



— 26 — 

Among the different remedies that have been 
used for the local treatment of fissure of the anus 
may be mentioned the following: Nitrate of silver; 
acid nitrate of mercury; fuming nitric acid; carbolic 
acid; sulphate of copper; the actual cautery, etc. 

Of these topical applications, the nitrate of silver 
is the best. Its effects are various: it lessens or en- 
tirely calms the nervous irritation which is so import- 
ant a factor in producing spasmodic contraction of 
the sphincters; it shields the raw and exposed mucous 
surface, by forming an insoluble albuminate of silver; 
it destroys the hard and callous edges of the ulcer, 
and tends to remove the diseased and morbid action 
of the parts. 

The form in which I usually employ this salt is 
in solution (from ten to thirty grains to the ounce). 
To attain the best results, the solution should be used 
once in twenty-four or forty-eight hours, according to 
circumstances. It may be applied by means of cot- 
ton attached to a silver applicator or cotton-holder 
(Fig. n), or to a piece of wood. The application is 



Fig. ii. — Cotton-Applicator. 

made by separating the margins of the anal orifice 
with the thumb and index finger of the left hand, and 
introducing into the anus the probe charged with the 
solution. 



— 27 — 

According to Bodenhamer,* if the ulcer is more 
than one-third of an inch above the margin of the 
anus it will be necessary to use the speculum. 

The solution is to be applied to the fissure only; 
a few drops are all that will be required. If thorough 
local anaesthesia has been induced by the use of 
cocaine, the application of the silver salt produces 
little if any suffering; for by the time the anaesthetic 
has lost its effect the acute pain caused by the nitrate 
of silver will have passed away. 

After each application the part should be well 
smeared with an ointment of iodoform (thirty grains 
to the ounce). The odor of the iodoform may be 
disguised by the addition of a. few drops of otto of 
roses. Iodol may be used instead of iodoform, and 
in the same way. 

After the ulcer has been touched once or twice 
with the silver solution, the effect will be, in those 
cases which are benefited by this treatment, a con- 
siderable mitigation of the severe pain which has 
troubled the patient when at the closet and after- 
wards; and the sore will present a healthy granu- 
lating appearance, and slowly contract in size. 

In children and in young persons, unless the fis- 
sure be complicated with some other affection, this 
lesion is almost always curable by adopting the fore- 
going mode of treatment. 

* Op. dt., p. in. 



— 28 — 

Some authorities speak highly of the use of the 
■acid nitrate of mercury, fuming nitric acid, carbolic acid, 
the actual cautery, etc., but in my experience their em- 
ployment is attended with more suffering than follows 
the employment of the nitrate of silver or the simple 
operative treatment which will presently be described. 
Furthermore, the application of these remedies is not 
so certain to effect a cure as either of the two pro- 
cedures just mentioned, so that I rarely resort to 
their use. 

The daily introduction of a full-sized bougie, made 
of wax or tallow, will sometimes act beneficially in 
€ases of fissure, by distending the sphincter and pro- 
ducing such an amount of irritation as will set up 
a healing process in the ulcer. An application of 
cocaine or of belladonna ointment should be made to 
the part prior to the employment of the bougie. 

Allingham * strongly advocates the local use of 
the following ointment: 

¥? Hydrarg. subchlor gr. iv. 

Pulv. opii gr. ij. 

Ext. belladonnse gr. ij. 

Ung. sambuci 3j. 

M. Sig. : To be applied frequently. 

This authority states that he has cured many 
cases with this ointment alone. 



* Op. at., p. 214. 



— 2 9 — 

Another excellent ointment recommended by Mr. 
Allingham* is the following: 

5 Plumbi acetatis J - gr x 

Zinci oxidi ) 

Pulv. calaminse gr. xx. 

Adipis benzoatis 5 ss. 

M. 

An ointment of red oxide of mercury, thirty 
grains to the ounce, has also cured many cases. 

The "Brinkerhoff System," as applied to fissures 
of the anus, is thus described by Dr.Edmund Andrewsrf 

"Once or twice a month, as the itinerant doctor 
comes around on his circuit, he inserts his little specu- 
lum, cleans out the ulcer, and applies to it a solution 
of nitrate of silver, forty grains to the ounce. Be- 
tween the applications the patient uses a morning and 
evening treatment himself. Each morning he is to 
evacuate the bowels, then inject the rectum with, luke- 
warm water, and finally insert into it a little ointment, 
consisting of three grains of carbolic acid and eight 
grains of sulphur to the ounce of vaseline or lard. 

" For evening treatment he uses 'Brinkerhoff's 
Ulcer Remedy,' having the following composition: 

$ Extract of hamamelis dist f I v. 

Solution of persulph. of iron f 3 j. 

Cryst. carbolic acid gr. ij. 

Glycerine f 3 ij. 

M. Sig.: Add half a teaspoonful of this to the same 
quantity of starch, and about an ounce and a half of water. 
Inject into the rectum every evening." 

* Op. cit., p. 215. 
j Op. at., pp. 75-76. 



— 3° — 

Operative Treatment. — In the more severe 
cases local treatment will fail to effect a cure, and 
operative interference will be necessary. There are 
three methods of repute to be considered in this 
connection: (i) forcible dilatation; (2) incision; (3) a 
combination of these two procedures, dilatation and in- 
cision. 

Forcible Dilatation. — This is the operation 
recommended by Recamier, Van Buren, and others. 
It consists in introducing the two thumbs into the 
bowel, back to back, and then forcibly separating 
them from each other until the sides of the bowel can 
be stretched as far out as the tuberosities of the 
ischia. It is essential to place the ball of one thumb 
over the fissure, and that of the other directly opposite 
to it, in order to prevent the fissure from being torn 
through and the mucous membrane being stripped 
off. As pointed out by Allingham,* it is well to re- 
peat the stretching in other directions until the entire 
circumference of the anus has been gone over. In 
this manner, by careful and thorough kneading and 
pulling of the muscles, the sphincters will be made to 
give way, and will be rendered soft and pliable. This 
procedure should always be done with the patient 
thoroughly under the influence of an anaesthetic, and 
should occupy at least five or six minutes. 

This operation is perfectly safe, but, as it is no 

* Op. cit., p. 221. 



— 3 1 — 

less severe than the operation by incision, and as in 
some cases it fails to effect a cure, I can see no ad- 
vantage in adopting it instead of the more satis- 
factory and always successful plan of treatment by 
combined dilatation and incision. It may be found 
preferable in some cases on account of the prejudice 
of patients against the use of the knife. 

Incision. — A fissure can be cured by this method, 
by making an incision through the base of the ulcer 
and a little longer than the fissure itself, so as to 
make sure of severing all the exposed nerve-filaments. 
The cut should divide the muscular fibers along the 
floor of the ulcer. 

In a fair proportion of cases this operation will 
meet with success, but it is not so certain and radical 
as the operation next to be described. 

It has the advantage over the other operations, 
however, of being nearly or entirely painless under 
local anaesthesia produced by cocaine, and therefore, 
when general anaesthesia is contra-indicated, or is re- 
fused by the patient, this method is worthy of a trial. 

Dilatation and Incision. — This operation, if 
skillfully and carefully performed, I believe to be a 
radical and unfailing cure for the disease. The bow- 
els should be cleared out by a dose of castor-oil and 
an injection; after which, under ether-anaesthesia, the 
sphincters should be dilated in the manner previously 
described. This being accomplished, and the ulcer 
properly exposed, a straight blunt-pointed bistoury 



— 32 — 

(Fig. 12) should be drawn deeply across the surface, 
making a cut about an inch in length and a third of 
an inch in depth. Instead of the blunt bistoury, a 



Fig. 12. — Blunt-pointed Bistoury. 

sharp-pointed scalpel may be used (Fig. 13). It should 
be entered at the margin of the anus, passed under 
the ulcer, and made to protrude above the ulcer, the 
overlying structure being then divided from without 
inward. 




Fig. 13. — Sharp-pointed Scalpels. 

The subsequent treatment consists in keeping 
the patient in the recumbent position, and in the use 
of a little opium to confine the bowels. After three 
or four days a laxative may be given, from which time 
daily alvine movements should be secured. In seven 
or eight days the patient can begin to move about; 
but for at least two weeks he should avoid standing 
long on the feet. No dressing is required further 
than bathing the parts with a little warm water and 
carbolic acid soap, to remove any offensive discharges. 



— 33 — 
For the same purpose, peroxide of hydrogen may be 
employed. 

The subcutaneous division of the sphinc- 
ters, as recommended by some authors for the cure 
of fissure, is not a satisfactory method, and is men- 
tioned here solely to condemn it. It is not only un- 
certain in its results, but is also painful, and in more 
than one instance has been followed by abscesses. 

3 JJJ 



Part 2.— Fistula in Ano. 



CHAPTER I. 

RELATIVE FREQUENCY — AGE AND SEX AF- 
FECTED—ETIOLOGY—CLASSIFICATION. 

Fistula in Ano which is not due to ulceration 
and perforation of the rectal wall from within is the 
result of a previous abscess. Such an abscess forms 
in the ischio-rectal fossa, and, although opened early 
by a free incision even before the cavity becomes dis- 
tended with pus, it frequently fails to heal. It may 
fill up and contract to a certain extent, but it does not 
become entirely obliterated; a narrow track remains, 
which constitutes the affection designated fistula in 
ano. 

There are several reasons why rectal abscesses 
so frequently degenerate into fistulas. One is, that, 
owing to an internal opening within the bowel, small 
particles of fecal matter find their way into the sinus, 
and, acting as foreign bodies, prevent the healing; 
another, that, owing to the frequent movement of the 
parts by the sphincter muscles, sufficient rest is not 
obtained for the completion of the reparative process; 



— 35 — 
and, finally, the vessels near the rectum are not well 
supported, and the veins have no valves, hence there 
is a tendency to stasis, which is unfavorable to rapid 
granulation. 

According to the authority of Mr. Harrison 
Cripps,* if the fistula be divided its surface will be 
seen to be lined with a smooth, gelatinous membrane, 
which when examined under the microscope is found 
to consist of granulation-tissue exactly analogous to 
that which lines the interior of a chronic abscess. 
The leucocytes constituting the outer wall of this 
membrane are but loosely adherent, and constantly 
becoming free they form the chief part of the pus 
which drains from the fistula. 

Relative Frequency of this Affection. — In 
point of frequency, compared with other rectal dis- 
eases, fistula is next to hemorrhoids. This statement 
is contrary to the showing made by the published sta- 
tistics of St. Mark's Hospital, as quoted by Ailing- 
ham, f This table shows that out of four thousand 
cases taken consecutively from the out-patient de- 
partment of the hospital there were one thousand 
and fifty-seven persons suffering from fistula and one 
hundred and ninety-six from abscess, of which latter 
number one hundred and fifty-one subsequently 
became fistula, so that more than one-fourth of the 
whole number of cases treated were fistula. Alling- 

* Op. at., p. 152. 
f Op. tit., p. 13. 



_ 36 - 

ham also states that a recent examination of* the 
records of the in-patients of the same institution, cov- 
ering a period of several years, shows that two-thirds 
of those operated upon were cases of fistula. 

Mr. Allingham* justly calls attention to one 
source of error in drawing conclusions from statistics 
— namely, the fact that many patients suffer from 
more than one malady. He states that it constantly 
happens that a fistula is found in connection with 
hemorrhoids, either as the substantive disease or as a 
complication. Again, a fissure or circular ulcer often 
has a sinus running from it, so that it may fairly be 
considered as the opening of an internal fistula, and 
the case called a fistula; or the sinus is not detected, 
and the case is called ulcer or fissure. 

Another fallacious element in the statistics of 
Mr. AllinghariL, which should not be overlooked, is. 
pointed out by Mr. Chas. B. Ball.f St. Mark's has a 
special reputation for the cure of fistula, so that many 
'persons suffering from this disease go there, and in 
this way the records show an apparent greater fre- 
quency of fistula. Mr. Ball also statesj that at the 
Dublin General Hospital, although fistula is common, 
it is by no means the commonest of rectal diseases;, 
and in his own practice this affection has not furnished 
more than one-sixth of rectal operative cases. 



* Op. cit., p. 13. 
f Op. cit., p. 66. 
X Op. cit., p. 67. 



— 37 — 

Age and Sex Affected. — This disease is com- 
monly met with during middle age, but it is by no 
means restricted to that period of life. Allingham 
states* that he has operated upon an infant in arms, 
and upon a man over eighty years old. Dr. Henry 
R. Whartonf mentions having seen a number of cases 
at the Children's Hospital, Philadelphia, among which 
he records one of complete fistula in a child a few 
months old. 

Causes. — Fistula in ano may originate in ulcera- 
tion and perforation of the mucous membrane of the 
bowel — the result of the irritation produced by fecal 
accumulations (arising from any cause, such as atony 
of the intestines, irregularity of habits, rectal stricture, 
etc.), or by foreign bodies, such as fish- or rabbit- 
bones, grape- or fig-seeds, etc.; more frequently it 
owes its origin to an abscess cause.d by injuries, such 
as blows or kicks upon the anus, or by exposure to 
cold, as from sitting upon damp seats — especially 
after exercise, when the parts are hot and perspiring; 
it may also arise from excessive irritation of the rec- 
tum occasioned by the presence of any of the forms 
of parasites which infest the anus and its immediate 
neighborhood. Other predisposing causes are throm- 
bosed veins and suppurating hemorrhoids. Abscess, 
and then fistula, may likewise supervene in fevers 



*Op. cit., p. 13. 

f Keating's " Cyclopaedia of the Diseases of Children,' 
vol. iii/p. 341. 



- 38 - 
and certain depressed conditions of the blood, such 
as frequently give rise to boils or carbuncles.* 

" The late Dr. W. E. Horner, Professor of 
Anatomy in the University of Pennsylvania, used to 
describe an arrangement of pouches opening upward, 
in the mucous membrane of the rectum, by which the 
entanglement of seeds, bits of bone, etc., contained in 
the feces was favored. His account may be found 
in his i Special Anatomy and Histology,' vol. ii, p. 46 
(edition of 185 1), where he quotes a paper on Fistula 
in Ano, by Ribes. He says, also, that Glisson and 
Ruysch had described them as valves, and that 
Winslow was acquainted with them. The latter 
author (Douglas's Transl., 1743, vol. ii, p. 149) says, 
' They form little bags or semilunar lacunae.' Another 
American writer, Bushe (' Malformations, Diseases, 
and Injuries of the Rectum and Anus,' 1837, p. 15), 
speaks of these pouches, and confirms Winslow's de- 
scription. They are also mentioned in the treatises 
of Leidy and S. G. Morton. Hyrtl (Handb. der 
Topogr. Anatomie, 187 1, bd. ii, p. 142) describes 
them quite fully, and speaks of their agency in the 
development of fistulas. 

" Mr. W. T. Clegg, of Liverpool, says (Lancet, Feb. 
5, 1881) that Mr. Bickersteth has for four years been 
describing these anal pouches, which 'are not men- 
tioned in any of the books he has consulted.' 



'Allingham, op. cit., p. 14. 



— 39 — 

" It is certainly strange that this arrangement, so 
clearly pointed out, should have been passed over in 
silence, not only by many anatomists, but by late 
writers on rectal surgery; yet it is undoubtedly a fre- 
quent cause of fistula. In Fig. 14 these pouches are 




Fig. 14. — Section of the Rectum, showing the rectal 
pouches, and a fistula with a bougie passed through it, the 
mucous membrane dissected off. At a is a small external 
pile, cut in half. — St. George's Hospital Museum, ser. ix, 
No. 42 (Holmes, Princ. and Pract. of Surgery, vol. ii, p. 643). 

shown, with a fistula, probably formed by a foreign 
body lodging in one of them. Over the fistula the 
mucous membrane has been removed, and a bougie 
has been passed through the canal."* 



•* Article on Diseases of the Rectum, by Henry Smith, 
Esq., revised by John H. Packard, M.D.. in Holmes' ll System 
of Surgery" (Packard, editor of American edition), vol. ii, 
pp. 643-644. 



— 4o — 

Finally, a tubercular or strumous diathesis seems 
to be as potent a factor in the causation of fistula as 
it is in other suppurative troubles. The appearance 
of a fistula in a tubercular subject is characteristic of 
the constitutional malady. It is thus described by 
Messrs. Alfred Cooper and F. Swinford Edwards :* 
" The part is, as a rule, unusually hirsute; the ischio- 
rectal fossae are drawn in, owing to absence of fat; 
the sphincter is weak and offers no resistance to the 
introduction of the finger. The skin around the 
orifice is bluish and often considerably undermined, 
and the discharge is thin and watery. The internal 
orifice is often large, and the mucous membrane 
around it is also undermined." 

The tendency to the occurrence of abscess and 
fistula in phthisical patients has long been recognized, 
and has given rise to some doubts as to the propriety 
of resorting to operative measures in such cases. 
This point will be considered in the chapter on Treat- 
ment. According to Messrs. Cooper and Edwards, f 
about five per cent, of phthisical subjects also suffer 
from fistula, and about twelve per cent, of fistulous 
patients are the subjects of tuberculosis. 

Varieties. — For all practical purposes we may 
divide fistulse into the following four forms: (1) the 
complete fistula, in which there are two openings, one 

* " Diseases of the Rectum and Anus/' second edition, 
London, 1892, p. 126. 
f Op. cit., p. 126. 



— 41 — 

in the rectum and one on the skin more or less re- 
mote from the anus (Fig. 15); (2) the incomplete in- 




Fig. 15. — Complete Fistula traversed by Probe (Esmarch). 

ternal fistula, in which there is a communication with 
the cavity of the rectum by means of an opening in 
the mucous membrane, but none with the external 




Fig. 16. — Internal Incomplete Fistula (Esmarch). 

surface of the body (Fig. 16); (3) the incomplete ex- 
ternal fistula, in which there is an external opening 



4 2 




Fig. 17. — External Incomplete Fistula (Esmarch). 




Fig. i3. 




Fig. 19. 



FISTULA WITH DOUBLE TRACKS (MOLLIERE). 

Fig. 18. — a, b, deep submuscular track resulting from 
an ischio-rectal abscess; a, 1, submucous track running up 
and down the bowel. 

Fig. 19. — d, e, subtegumentary and submucous fistula 
with internal and external opening; D, F, deep submuscular 
track, having same internal but separate external opening. 



— 43 — 
through the skin, but no communication with the bowel 
(Fig. 17); and (4) the complex fistula, in which there 
are many sinuses and numerous external openings 
(Figs. 18 and 19). Some of these tracks run outward; 
some extend up the bowel beneath the mucous mem- 
brane; whilst others travel round the bowel and open 
in the other buttock, giving rise to the so-called horse- 
shoe fistula. The second and third varieties named 
are often spoken of as blind fistulae. 



CHAPTER II. 

SYMPTOMATOLOGY— PHYSICAL EXPLORATION 
—DIAGNOSIS— PROGNOSIS. 

Symptoms. — The symptoms of fistula are not 
easily overlooked. Occasionally there is considera- 
ble pain present, but more frequently only a feeling 
of uneasiness about the anus is experienced. When 
a fistula originates, as I believe it most commonly 
does, from a preexisting abscess, there is a sensation 
of weight about the anus, with swelling of the integu- 
ment, considerable tenderness upon pressure, pain in 
defecation, and a constitutional disturbance associ- 
ated with rigors. These symptoms are relieved after 
the matter is discharged. The exploring needle (Fig. 
26) is often useful in determining the presence of pus 



Pig. 20. — Small Trocar and Acupuncture or Exploring Needle 
(for testing the character of ambiguous swellings or fluid 
collections about the rectum). 

in such abscesses in which it is impossible to obtain 
fluctuation. In complete fistula in ano, and in the 
incomplete internal variety, the evacuations are 
streaked or covered with pus and mucus, perhaps 
also slightly tinged with blood. 

The chief discomfort to a patient with fistula is 



— 45 — 
the discharge, in greater or less quantity, of purulent 
or muco-purulent matter which is kept up from the 
sinus so long as it remains unhealed, soiling the linen 
and making it wet and uncomfortable, and producing 
an excoriation of the nates. The discharge is not of 
itself sufficient to be a source of great exhaustion, 
and does not interfere with ordinary occupations, so 
that many patients have had fistula for a considerable 
length of time without being conscious of any serious 
ailment. The escape of flatus and mucus from the 
bowel in complete, fistula will often prove a source of 
annoyance, as will also the passage of feculent matter 
which will be expelled through the sinus should the 
fistulous channel be very free. 

An attack of secondary suppuration is always 
liable to complicate the presence of a fistula, and is 
usually due to a stoppage of the track by small parti- 
cles of feces or by exuberant growth of the granula- 
tions. Such a sequela, of course, is attended with 
pain, until a new opening forms or one is made by 
the surgeon. In some cases the original fistulous 
track becomes reestablished. Fistula in some persons, 
particularly those of a nervous temperament, pro- 
duces an impression of physical imperfection and 
weakness in their organization, which renders them 
miserable. As in other affections of the rectum, vari- 
ous reflex or sympathetic pains are experienced in 
cases of fistula; they are referred to the back, to the 
loins, and to the bottom of the abdomen. When such 



- 4 6 - 

pains extend down the leg and to the foot, they are 
likely to be attributed to sciatica unless the history 
of the case is carefully studied and a critical exami- 
nation made. 

Ocular and Digital Examination. — Imme- 
diately before an examination is made in cases of fis- 
tula, as well as in all other investigations connected 
with the diagnosis of rectal diseases, the bowels should 
be emptied by an enema. This procedure not only 
renders the exploration of the parts easier and 
cleaner, but also, in women especially, serves to quiet 
the patient's fears of any untoward accident occurring, 
and therefore facilitates the thoroughness of the sur- 
geon's examination by securing the cooperation of the 
patient, as in extruding the parts, etc. 

In order to examine a patient with supposed 
fistula, he should be placed in a recumbent position 
on a table or an examining-chair, preferably on the 
side on which the external opening is situated, with 
the legs well drawn up toward the abdomen, and the 
buttocks brought to the edge of the couch. 

The anus and the surrounding parts should be 
carefully examined to detect any apparent lesion. If 
the external orifice of the sinus is prominent, or if 
there is a sentinel granulation present, the outlet of 
the fistula will be obvious; but when it is small and 
located between folds of the skin, its situation may 
be demonstrated by making pressure with the top of 
the finger in the suspected locality, which will usually 



— 47 — 
cause a little drop of matter to exude. The site of a 
fistula may often be detected by feeling gently all 
around the anus with the forefinger and finding an 
induration which feels like a pipe-stem beneath the 
skin. A flexible silver probe (Fig. 21) should now be 



Fig. 21. — Silver Probe attached to handle. 

passed along the fistulous track. In doing this, con- 
siderable care is requisite, and the utmost gentleness 
should be observed, bearing in mind that the probe 
is to be directed by its own weight through the sinus, 
and not by force applied by the hand of the surgeon. 
If it does not pass easily, bend it and see if it cannot 
be coaxed along the channel. In many cases it will 
pass directly into the bowel. When the probe has 
been passed as far as it will go without the use of 
any force, introduce the finger gently into the rectum. 
This should be subsequent to the passage of the 
probe, as otherwise the introduction of the finger into 
the bowel will set up a spasm of the sphincter muscles, 
which will greatly interfere with the passage of the 
probe. When the finger is in the bowel it will fre- 
quently come in contact with the probe, which fact 
demonstrates the presence of a complete fistulous 
track; in other cases the mucous membrane is felt to 
intervene between the digit and the probe. In such 
cases the internal opening generally exists, but is 



- 4 8 - 

difficult to discover,— sometimes because the examiner 
searches for it too high in the bowel. Palpation with 
the sensitive tip of the finger will often render the 
presence of the inner orifice obvious, by coming in 
contact with an indurated mass of tissue. If such a 
spot be felt, the finger should be placed upon it and 
the probe passed toward the finger. Make sure that 
the fistula is a complete one, by feeling the probe 
touch the finger. There may not be an internal 
opening; if not, see how near the probe comes to the 
surface of the bowel. 

If a doubt still exists as to the completeness of 
the track, one of a variety of specula (Figs. 22, 23, 
24) may be introduced into the rectum, and the outer 




Fig. 22. — Pratt's Speculum. 

orifice of the sinus injected with either milk or a so- 
lution of iodine, when if there be an internal open- 
ing the appearance of the colored fluid within the 
bowel will set the question at rest. 



— 49 — 

If the inner opening be not discovered by these 
methods, the case must be looked upon as one of ex- 
ternal rectal fistula. 




Fig. 23. — O'Xeil's Speculum. 




Fig. 24. — Kelsey's Rectal Retractor. 

According to Ball,* in cases where the probe 
passes away from the rectum and is directed along 



*Op. cit.\ p. 77. 

4 jjj 



— 5° — 
the anal fascia to the upper portion of the ischio-rectal 
fossa, or where the entire substance of the rectal wall 
separates the finger and the probe, the case is one 
either of external rectal sinus, or of fistula originating 
in the superior pelvi-rectal space. In such cases, Mr. 
Ball states, " we must go farther and try and find 
the cause, such as diseased bone, etc.; and in the 
female a vaginal examination may show us a uterine 
or ovarian origin. Where there are numerous exter- 
nal openings it is necessary to carefully probe all of 
them, so as ta determine whether they are all con- 
nected,, and the direction which they take. The 
upper limit of the separation of the mucous membrane 
should also be made out, and search should be made 
for the presence of more than one internal orifice, if 
such is likely to be present." 

The presence of incomplete internal rectal fistula is 
more difficult to determine than the other varieties of 
this lesion which have just been considered. It is the 
most painful form, but, fortunately, it is of infre- 
quent occurrence. Its orifice may be located any- 
where in the rectum, but is generally found between 
the internal and external sphincters. According to 
Allingham,* the circumference of this opening is 
often as large as an English threepenny piece, its 
edges being sometimes indurated, at other times 
undermined. The feces, when liquid, pass into the 

* Op. cit. y p. 21. 



— 5i — 

sinus and create great suffering — a burning pain 
often lasting all day after the bowels have acted. 

In this variety of fistula the feces are coated 
more or less with pus or blood, and a boggy swell- 
ing is noted at some portion of the circumference 
of the anus. A peculiar feature of this swelling is 
often noted — viz., its presence one day and its dis- 
appearance in a day or two, followed by an increased 
discharge of pus from the bowel. This fact is 
explainable by the closure of the outlet of the fistula, 
caused either by a plug of feces or as a result of 
inflammatory swelling, which allows the collection of 
a quantity of pus and the consequent formation of a 
boggy tumor. The swelling disappears upon the 
reestablishment of the communication between the 
bowel and the sinus, and is attended by the profuse 
discharge of matter previously mentioned. This 
phenomenon is repeated over and over again, and 
indicates the nature of the disease. 

In other cases of blind internal fistula, if the ori- 
fice can be felt, or if it can be seen through a specu- 
lum, a bent probe may be introduced into it and 
made to protrude near to the cutaneous surface of the 
body, where its point can be felt. 

Diagnosis. — The method of diagnosing fistula 
has already been sufficiently detailed. A few words, 
however, as to differential diagnosis may prove use- 
ful. Fistulae frequently coexist with other rectal dis- 
eases; it is therefore important that an examination 



— S 2 — 
should be carefully made, so as to exclude such 
lesions — for instance, the presence of stricture, malig- 
nant disease, hemorrhoids and other tumors, etc. A 
thorough physical examination of the chest should 
also be made, to ascertain the presence or absence of 
phthisis, which so frequently complicates fistula in 
ano. Serious kidney disease should be excluded 
before recommending operation, for obvious reasons. 
In cases of caries of the vertebrae, of the sacrum, or of 
the pelvis, fistulous tracks may form and simulate anal 
fistula. In such instances a careful investigation will 
reveal the true origin of the trouble, and will show 
that the case is not one of ordinary fistula in ano. 

Course and Prognosis. — This disease untreated 
has a tendency to increase. The longer its duration 
the more tortuous and complicated does it become. 
Hence the earlier the patient submits to treatment 
the more favorable will be the prognosis, and the 
time and extent of the treatment necessary to effect a 
permanent cure will be correspondingly diminished. 



CHAPTER III. 

THE PALLIATIVE TREATMENT OF FISTULA IN 

ANO. 

Treatment of Abscess. — Preliminary to a con- 
sideration of the treatment for the disease when the 
fistulous track has been formed, some attention must 
be devoted to the importance of dealing promptly 
with the inflammatory and suppurative process which 
leads to abscess, and which usually forms the first 
stage of the affection known as fistula in ano. 

When a patient presents the symptoms of a 
threatened abscess in the vicinity of the rectum, he 
should be directed to go to bed, or at least to 
avoid all undue exercise; the bowels should be 
thoroughly evacuated, preferably by the use of a 
saline cathartic; the diet should be nutritious; and, if 
the case be seen early, hot fomentations and poultices 
may be applied to the parts. The early adoption of 
these measures may abort the threatened abscess. 

If, however, there be reason to suspect that 
matter has formed or is forming, it will be advisable 
to make a free incision into the center of the affected 
site with a sharp curved bistoury, if the trouble is 
superficial, or, if it is deep, with a narrow straight 
knife. When pus is present and is deeply seated, the 
evacuation of the abscess will be aided by the intro- 
duction of the forefinger into the bowel, by which 



— 54 — 

means the swelling may be pushed forward, rendered 
tense, and hence made more apparent. 

In opening- these abscesses, if possible, ether 
should be given. The patient should lie on the side on 
which the threatened abscess is situated; the upper leg 
should be bent forward upon the abdomen. When 
pus is present, the operator should stand out of the 
line of its exit, for when the cavity is opened it often 
squirts out a considerable distance. After the matter 
has been discharged, the forefinger should be intro- 
duced into the abscess-cavity for the purpose of 
breaking down any secondary cavities or loculi that 
may exist. When this has been accomplished, the 
abscess should be thoroughly washed out with per- 
oxide of hydrogen (Marc hand's, undiluted, or some 
other reliable preparation), after which a rubber 
drainage-tube should be inserted, or a piece of iodo- 
form gauze should be lightly placed between the lips 
of the incision, to prevent its closing too rapidly, and 
also to allow free drainage. Careful daily attention 
should be paid to the wound while the cavity of the 
abscess is contracting, as it is important to maintain a 
free and dependent outlet for the matter which con- 
tinues to be secreted; but stuffing and distention of 
the cavity should be avoided. If a drainage-tube be 
used, it should be shortened from day to day as the 
wall of the abscess contracts. 

After an operation for rectal abscess, the patient 
should be kept quiet for several days; and if great 



— 55 — 
care be taken, both with the subsequent drainage and 
in keeping the orifice open, the part may heal without 
the formation of a fistula. 

Treatment of Fistula in Ano. — The treat- 
ment of fistula, like that of fissure, may be either 
palliative or operative. 

Palliative Treatment. — This method of treat- 
ment will be required in cases where there is a posi- 
tive refusal on the part of the patient to submit to 
an operation, and in persons whose constitutions are 
broken down by disease and in whom the reparative 
powers of the body are not equal to the task of re- 
storing it to health. Chronic alcoholism, albuminuria, 
diabetes, malignant diseases, etc., are conditions in 
which operative procedures are attended with risk, 
and in which palliative measures should be tried. 
Phthisis is not an absolute contra-indication to opera- 
tive measures. The rule which I observe is to oper- 
ate in those cases of tubercular subjects in which the 
disease is quiescent, but to avoid such interference if 
the lung-mischief is at all active. 

Incomplete external fistulae, and even complete 
fistulse of somewhat recent origin and not extensively 
indurated, may be cured by non-operative measures; 
but such treatment requires constant attention on the 
part of the practitioner, as well as a willingness on 
the part of the patient to give sufficient time to the 
treatment. Even under such circumstances the pro- 
cess of repair is slow, and in many cases the result 



-56- 

will not be perfectly satisfactory. It is true that 
fistulae sometimes recover spontaneously, or are cured 
by simple means, such as the mere passage of a probe 
used in examining the fistulous track, but instances of 
this kind are rare. 

In certain selected cases of fistulae I am in the 
habit of endeavoring to effect a cure by stimulating 
the sinus and allowing free drainage of the secretions, 
so as to avoid the use of the knife. To accomplish 
satisfactory results with this mode of treatment, the 
following indications should be borne in mind: i, 
that the external orifice be perfectly free; 2, that the 
sinus be kept clean, so as to prevent putrefactive 
changes; 3, that an effort be made to excite a healthy 
action in the fistulous channel; and 4, that the parts 
be kept as quiet as possible. 

To meet the first indication, it is necessary to 
dilate the outer opening of the fistula with sponge or 
sea-tangle tents: but better still for this purpose are 
the Lee's Antiseptic Slippery-Elm Tents (Fig. 25).* 




Fig. 25. — Slippery-Elm Tent (large size). 

These are made of selected slippery-elm bark, and 
compressed under high pressure. Owing to their 



*Made by J. Elwood Lee Co., Conshohocken, Pa. 



— 57 — 
non-irritant and demulcent properties, I find them 
superior to other tents. 

The second indication (that the sinus be kept 
clean, so as to prevent putrefactive changes) is best 
carried out by the use of peroxide of hydrogen. I 
have cured some cases of fistula in ano by means of 
injections into the sinus of peroxide of hydrogen 
alone, being careful to keep the external opening free, 
and treating the patient daily until healing occurred. 
I am in the habit of using Marchand's preparation, 
undiluted. It is injected into the sinus by means of 
a long, flexible silver canula (Fig. 26) attached to a 
hypodermatic syringe. 

Fig. 26. — Flexible Silver Canula. 

Other antiseptics may be employed for the same 
purpose, such as bichloride of mercury (1 to 2000), or 
carbolic acid (1 to 80), but I much prefer the per- 
oxide of hydrogen. 

The third indication (to excite a healthy action 
in the sinus) can be met in one of a number of ways. 
In the first place, before applying such remedies it 
will be well to obtund the sensibility of the channel 
by an injection into the sinus of a four-per-cent. solu- 
tion of cocaine. This may be accomplished by using 
the same syringe and canula that are used for cleans- 
ing the fistula. 



- 58 - 

If the wall of the sinus is somewhat indurated, 
it is better to insert a small, flexible curette (Fig. 27) 
and scrape the wall of the fistula along its entire 




Fig. 27. — Flexible Curette. 

length. The sinus is now prepared for some one of 
the various stimulating substances which have been 
recommended for this purpose. Among these may 
be mentioned peroxide of hydrogen; nitrate of silver, 
fused, or in solution (thirty to sixty grains to the 
ounce); sulphate of copper in solution (ten grains to 
the ounce) ; carbolic acid mixed with equal parts of 
glycerine and water. 

These substances may be applied to the fistulous 
track by means of cotton attached to a silver probe or 
to an applicator (Fig. 11, p. 26); or they may be in- 
jected into the sinus by means of the syringe and sil- 
ver canula (Fig. 26, p. 57). 

If the fistula is a complete one and the sub- 
stance used be applied as an injection, the finger 
should be passed into the rectum and made to cover 
the internal orifice of the sinus, so as to prevent the 
escape of any of the fluid into the bowel. 

Regarding the fourth point (keeping the parts at 
rest), the patient, whilst under treatment, should be 
confined to the horizontal position, either in bed or 
on a sofa. Congestion of the parts is thereby less- 



— 59 — 
ened. A firm pad placed over the anus and well 
supported by a T-bandage is useful in limiting the 
motions of the anus due to the alternate contraction 
and relaxation of the levator ani muscle. 

The chance of success in the palliative treatment 
of fistula in ano will be greatly increased if due at- 
tention be paid to the general state of health of the 
patient, and when circumstances render it possible he 
should be advised to seek the benefits of a change of 
air. 



CHAPTER IV. 

THE OPERATIVE TREATMENT OF FISTULA 
IN ANO. 

In all cases of fistula in ano, before undertaking 
operative interference it is essential for the surgeon 
to examine the patient carefully, not only locally, but 
also as to the general state of health; for this disease 
is not infrequently complicated with other lesions — 
as has been previously mentioned — which may render 
operative procedures inadvisable. 

Thus, when a fistula is associated with a stricture 
of the rectum of a malignant nature, any operative 
interference on the former lesion will be out of the 
question. If it is a simple stricture and its existence 
be not recognized, or if it be left untreated, any oper- 
ation performed on the fistula will fail to effect a cure. 

Treatment by Incision. — In a large majority 
of cases of fistula in ano, the operation which is sanc- 
tioned by experience as the most prompt and certain 
at the same time that it is the safest in its results is 
to lay open the sinus into the rectum, dividing with 
the knife all the tissues intervening between its cavity 
and that of the bowel. Figs. 28, 29, 30 and 31 repre- 
sent useful forms of knives for incising a fistula. 

The preparation of the patient consists in having 
the bowels moved by means of castor oil or some 
other mild cathartic on the day preceding the opera- 



— 6i — 

tion, and on the morning of the operation the lower 
bowel should be evacuated by means of an enema. 




Fig. 28. — Blunt-pointed Knife. 




Fig. 29. — Curved Knife, useful in certain fistulous cases. 




Fig. 30. — Gowlland's Bistouries. 




Fig. 31. — Kelsey's Fistula-Knife. 



— 62 — 

After etherization the patient should be placed 
on the side on which the fistula exists, the buttock 
being brought to the edge of the operating-table. 
Occasionally the lithotomy posture is preferable, as in 
cases in which there is a complex fistula. 

The first step in the operation is to dilate the 
sphincter muscles, which is to be done in a slow but 
steady manner by introducing the thumbs into the 
rectum, back to back, and making gradual pressure 
around the anal orifice until muscular contraction is 
overcome. 

In dealing with complete fistula a flexible 
probe-pointed director (Figs. 32, 33) is passed through 




Fig. 32. — Probe-pointed Director. 



Fig. 33. — Kelsey's Fistula-Director. 

the sinus, and is then brought out of the anus by 
means of the forefinger of the left hand introduced 
into the bowel. The tissues lying upon the director 
are then to be divided with a sharp bistoury. A care- 
ful search is now to be made for any diverticula, 
which if found should be divided. If none exist, the 
granulations lining the track should be scraped away 



- 63 - 

with a Volkmann's spoon (Fig. 34). The healing 
process will be facilitated by removing with scissors 
all overtopping edges of skin and mucous membrane. 



Fig. 34. — Volkmann's Spoon. 

If the internal opening is more than an inch from 
the anus, a probe-pointed bistoury (Figs. 28, 30, p. 61) 
should be introduced into the fistula upon a director, 
and its point made to impinge upon a finger in the 
rectum. As the finger and the instrument are with- 
drawn, the necessary incision is made. Or the 
director can be passed through the sinus, and a 
wooden gorget (Fig. 35) inserted into the bowel, after 




Fig. 35. — Gorget. 

which the track can be divided with an ordinary bis- 
toury. The gorget prevents the opposite side of the 
bowel from being injured should the knife slip. (Fig. 

36). 

When the track of the fistula is much indurated, 
and considerable force is therefore required to make 



-6 4 - 

the incision, it will be better to perform the operation 
by means of Mr. Allingham's spring-scissors and 




Fig. 36. — Operation for Fistula with Gorget (Bernard and 
Huette). 




Fig. 37. — Allingham's Spring-Scissors and Director. 



- 65 - 

special director (Fig. 37), With this instrument, fistulse 
running high up in the bowel may be divided, no 
matter how dense they may be. The director is made 
with a deep groove, the transverse section of which is 
more than three-quarters of a circle; in this the globe- 
shaped probe-point of one blade of the scissors runs. 
When placed in the groove the blade cannot slip out; 
so, the director having been passed through the sinus, 
the forefinger of the left hand is introduced into the 
bowel, and then the probe-pointed blade of the scis- 
sors is inserted into the groove of the instrument, and 
run along it, cutting its way through the diseased tis- 
sue as it goes, the finger in the bowel preventing the 
healthy structure from being wounded. 

A frequent error in operating on fistulous cases 
consists in not keeping to the sinus, the director 
being pushed through the track-wall, and then being 
free to roam about in the cellular tissue of the part, 
at the operator's will. In this manner a portion of 
the fistulous channel is left, and an unnecessary 
amount of the tissues (skin and subcutaneous struc- 
tures) is divided. Such a mistake can always be 
avoided by taking plenty of time in performing the 
operation, and by careful sponging of the sinus as it 
is laid open, in order to follow the track of the 
granulation-tissue lining it, which by this simple 
means is freely exposed to view. 

The method of treating external rectal fis- 
tula must vary according to the direction and extent 

5JJJ 



— 66 — 

of the track. If the mucous membrane alone inter- 
venes between the finger introduced into the bowel 
and a probe passed along the sinus, the channel 
should be transformed into a complete fistula by per- 
forating the mucous membrane with the probe, or 
with a director, at the uppermost limits of the fistu- 
lous channel. The regular operation for complete 
fistula is then to be performed by dividing the inter- 
vening septum between the fistula and the bowel. 

In cases in which the sinus is directed away from 
the rectum, the proper course is not to divide the 
sphincters, but freely to enlarge the external orifice 
and to maintain free drainage. 

The treatment of incomplete internal rectal 
fistula: invariably demands operative interference 
at the earliest possible moment after a diagnosis is 
made; for if left alone its tendency is to burrow. 

The operation for a blind internal fistula consists 
in making it a complete fistula and in dividing the 
intervening structures between the bowel and the 
sinus. This is best performed by introducing a probe- 
pointed director, bent at an acute angle, into the 
bowel, and passing the bent portion through the in- 
ternal opening. This done, the point of the probe 
can be felt subcutaneously and cut down upon, and 
the remainder of the operation completed. 

In dealing with complex fistula the surgeon 
must be guided by the peculiarities of each case. In 
operating upon a horseshoe fistula it is essential to 



- 67 - 

recognize the true condition of affairs; for a careless 
or an inexperienced observer might think that he had 
two separate fistulae to deal with, and operate accord- 
ingly. Even were he to recognize that he was deal- 
ing with a horseshoe fistula, if he followed the usual 
plan he would slit up first one sinus and then the 
other, dividing the sphincter in two places obliquely 
through its fibers, thus endangering the patient's 
future power of controlling the movements of the 
bowel. (Fig. 38.) 

ft 

Fig. 38. — Diagram show- Fig. 39. — Diagram show- 

ing wrong method of oper- ing the method recom- 
ating in horseshoe fistula. mended in operating upon 

horseshoe fistula. 

According to Messrs. Cooper and Edwards,* " If 
this fistula can be laid open in such a way as to entail 
only one division of the sphincter, and that at right 
angles to its fibers, there will be a minimum amount 
of risk of subsequent incontinence." The operation 
can be done in this way (Figs. 39, 41, 43). First pass 
a probe-pointed director through the internal aper- 
ture, and on its point incise the skin in the middle 




* Op. cit., p. 119. 



— 68 — 

line behind; now push the director through, and slit 
up. Secondly, slit up the lateral sinuses on directors 
passed in at the external openings and brought out at 
the dorsal incision. These lateral sinuses may take 
a straight, a curved, or even a rectangular direc- 
tion. Fistulae taking these different courses are illus- 
trated in Figs. 40 and 42. 





Fig. 40. — A diagram of Fig. 41. — Diagram of in- 

one variety of horseshoe cisions necessary, 
fistula. 

" The first incision will have divided the sphinc- 
ter, but the other two will only have divided tissue 
external to it. Should the external apertures be so 
placed that a straight line drawn from the one to the 
other would pass behind the anus (Fig. 40), the steps 
of the operation could be reversed, and a director be 
passed in at one external orifice and out at the other, 
and the tissues divided. Now pass the director from 
the wound in the middle line into the bowel, through 
the internal opening, and slit up the tissue with the 



- 69 - 

included sphincter. In this way the incisions will be 
found to be more or less T-shaped, the stem corre- 
sponding to the dorsal cut." 




Fig. 42. — A diagram of 
severe horseshoe fistula, with 
five external openings. 




Fig. 43. — Diagram show- 
ing incisions necessary for 
the cure of foregoing with 
one division of sphincter. 



Treatment of Hemorrhage. — There is seldom 
much hemorrhage after an operation for fistula, but 
in some cases it may be necessary to ligate a large 
vessel which has been divided. If there should be a 
profuse general oozing, the sinus may be packed with 
iodoform gauze, or, if necessary, the rectum may be 
plugged; for this purpose Allingham ties a double 
string into the center of a large bell-shaped sponge, 
which is passed into the bowel so as to prevent the 
blood from escaping upward into the colon. He then 
firmly packs the parts below with cotton dusted with 



— 7 o — 

powdered alum or persulphate of iron. In order to 
allow the escape of flatus, a catheter may be passed 
through the sponge. As a rule, all hemorrhages fol- 
lowing rectal operations are easily controlled by mild 
measures, such as the local application of hot water, 
of ice, or of some mild astringent. 

The After-Treatment. — After the operation 
for fistula in ano, the wound should be packed with 
iodoform gauze, which is left undisturbed for twenty- 
four hours. This is done to prevent subsequent 
hemorrhage. A pad of gauze and cotton and a T- 
bandage are next applied. 

The subsequent dressing of the case should be 
daily attended to by the surgeon himself. The parts 
should be kept perfectly clean, and the wound 
syringed with peroxide of hydrogen, carbolic acid 
solution, etc., after which a single piece of iodoform 
gauze laid between the cut surfaces of the wound 
will be all the dressing required. 

In the after-treatment of these cases I have seen 
the healing process greatly retarded by excessive 
packing of the wound with the lint, or delayed by the 
undue use of the probe. Such interference is to be 
avoided 

If the granulations are sluggish, and the dis- 
charge is thin and serous, it will be well to apply some 
stimulating lotion, such as peroxide of hydrogen or a 
weak solution of copper sulphate, (two grains to the 
ounce). 



— 7i — 

The surgeon should be on the watch during the 
healing process to avoid any burrowing or the forma- 
tion of fresh sinuses. Should the discharge from the 
surface of the wound suddenly become excessive, it is 
evidence that a sinus has formed, and a careful search 
should be made for it. Sometimes it begins under 
the edges of the wound, at other times at the upper 
or lower ends of the cut surface, and occasionally it 
seems to branch off from the base of the main fistula. 

Pain in or near the seat of the healing fistula is 
another symptom of burrowing, and when complained 
of the surgeon should carefully investigate its cause. 

After an operation for fistula, the patient's bowels 
should be confined for three or four days, for which 
purpose opium is usually given. At the end of this 
time the bowels may be opened by the administration 
of a dose of castor-oil, and so soon as the patient feels 
a desire to go to stool an enema of warm water 
should be injected, which will tend to render the 
feces soft and fluid and hence make their passage 
easier. The patient should be kept in a recumbent 
posture until the fistula is healed; and until the 
bowels are moved the diet should be liquid — such as 
milk, beef -tea, and broths. The time required for a 
patient to recover after an operation for fistula in ano 
varies with the extent of the disease. In an average 
case it will be necessary to keep the patient in bed 
for two or three weeks, and confined to the house for 
a couple of weeks longer. 



— 72 — 

Incontinence of feces is an unpleasant sequela 
to the operation for fistula. It is, happily, of rare 
occurrence, and follows only extensive operations, 
such as those in which the sphincter has been divided 
more than once, etc. When it exists to any extent it 
is productive of great annoyance to the patient, pos- 



XS^X^SuttS 



=*C? 



Fig. 44. — Set of three Cautery Irons to fit one handle. 




Fig. 45. — Paquelin's Thermo-Cautery. 



— 73 — 
sibly more so than the original fistula. The appli- 
cation of the old-fashioned cautery-iron (Fig. 44), 
heated to the proper degree, or the small point of 
Paquelin's thermo-cautery (Fig. 45), applied to the 
cicatrix of the operation wound, will often suffice to 
relieve this trouble, by causing contraction of the 
anal outlet and giving tone and increased power to 
the sphincter muscle. 

Mr. H. W. Allingham, Jr.,* recommends for this 
condition freeing the ends of the muscle by a deep 
incision through the old cicatrix and allowing the 
wound once more to heal from the bottom by granu- 
lation. 

Dr. Chas. B. Kelseyf advocates in these cases 
the complete excision of such a cicatrix, exposing 
freely the divided ends of the sphincter and bringing 
them together by deep sutures, exactly as in cases of 
lacerated perineum. 

In dealing with a fistula situated anteriorly in a 
female subject, Messrs. Cooper and Edw r ards J recom- 
mend that after a free division of the sinus the track 
be scraped thoroughly with a Volkmann's spoon, and 
then deep sutures inserted as in the case of rupture of 
the perineum, in the hope by this means of getting 
union by first intention. 



* Medical Press and Circular, May 23d. 
f Annual of the Universal Medical Sciences, 1889, vol. 
iii, p. 5, D. 

X Op. cit., p. 124. 



— 74 — 

Treatment by Immediate Suture. — In other- 
wise healthy subjects, affected with fistula in ano, a 
method of operating which has met with success, 
especially in this country, consists in the immediate 
suture of the wound after the fistula has been excised. 
The steps of the operation are as follows. The sep- 
tum between the fistula and the bowel is divided; the 
entire fistulous channel, and all lateral sinuses, are 
excised; buried sutures of catgut or of silk are then 
passed around the wound, at intervals of a quarter of 
an inch, and tied so as to bring the deep tissues 
together. The sutures are inserted very much in the 
same manner as in the ordinary operation for ruptured 
perineum. The advantage of this plan of treatment 
is that primary union is secured and the patient re- 
covers in a shorter time than would have been the 
case after one of the operations which aims to secure 
union by granulation. 

Treatment by Ligature. — There are two 
methods of using the ligature, which we may term the 
immediate and the mediate. 

The immediate operation has little to recom- 
mend it. It consists in passing a silk thread through 
the fistula and drawing it backward and forward so 
as to cut its way through. The same object may be 
accomplished by the use of the galvanic ecraseur, or 
of the wire ecraseur of Chassaignac. 

Mediate Operation by Ligature. — In this 
method either the silk ligature or an elastic one may 
be employed. 



— 75 — 

Silk Ligature. — If silk be used, it may be em- 
ployed in one of two ways. In both methods a short 
piece of silk is threaded to a silver probe bent to a 
curve, which is passed through the fistula and drawn 
out at the anus. The thread is passed through the 
track, so that one end hangs out of the bowel and the 
other at the external orifice of the fistula. It is at 
this point that the methods diverge. One plan con- 
sists in knotting the ends loosely together and allow- 
ing the patient to go about. After a time, ranging 
from two to four weeks, the ligature comes away, 
having slowly cut through the included tissue. Ac- 
cording to Mr. Harrison Cripps,* the pathological 
process by which this is accomplished appears to be a 
gradual destruction or disintegration of the included 
tissue, due to the ulcerative action of the thread. 
The other plan is to tie the silk so tightly that it will 
completely cut its way through and strangulate all 
the tissue requiring division in an ordinary case of 
fistula. This method causes considerable suffering to 
the patient, and has therefore been discarded in favor 
of the operation next to be described. 

Operation by Elastic Ligature. — The advo- 
cates for the use of the elastic ligature maintain that 
with it there is no hemorrhage. This is a matter of 
considerable importance when the fistula penetrates 
deeply, and also in those rare cases of hemorrhagic 

* Op. cit., p. 181. 



- 76 — 

diathesis where severe bleeding is apt to follow a 
trivial incision. 

For the introduction of the elastic ligature we 
are indebted chiefly to Dittel, of Vienna. This liga- 
ture causes strangulation of the parts by the firm 
pressure it constantly exerts upon the included struc- 
tures; it cuts its way out in a week's time or less. 

It is stated by those who have an extended ex- 
perience with this plan of treatment, that, contrary 
to what might be expected, the pain attending the 
ulceration of the band through the tissues is slight, 
especially after the first twelve hours. Consequently, 
this method would prove an excellent way of treating 
fistula if it were always to be relied upon to effect a 
cure. Unfortunately, this is not the case, for it often 
happens that after the ligature has cut its way 
through, and the superficial parts have healed, the 
fistula remains uncured. The reason for this is to be 
found in the fact that the ligature has dealt with the 
main track, only, of a fistula in which exist one or 
more secondary channels and diverticula. I there- 
fore resort to this method of treatment only in that 
class of patients who have an insuperable dread of 
any cutting operation; when the fistula is uncompli- 
cated with sinuses; in cases of deep fistula where 
there is danger of wounding large vessels; in cases in 
which the patients are debilitated by means of some 
chronic disease; and, finally, in patients of known 
hemorrhagic tendency. It is a valuable adjunct to 



— 77 — 
the use of the knife in dealing with cases in which a 
sinus runs for some distance along the bowel. 

The method of employing this ligature is as fol- 
lows. A solid cord of india-rubber, about one-tenth 
of an inch in diameter, may be threaded to a probe 
having at one end a rounded opening, or eye, through 
which the ligature is passed. The probe enters the 
fistula from the external to the internal opening, and 
passes out through the anus. To facilitate the pas- 
sage of the cord, the rubber should be put on the 
stretch. After the ligature is passed, a soft metallic 
ring is slipped over the two ends of the cord; the 
cord is then tightly stretched and the ring slipped up 
as high as possible and clamped. 

If the internal opening be any distance up the 
bowel, Allingham's instrument (Fig. 46) facilitates the 




Fig. 46. — Allingham's Ligature-Carrier. 

passage of the ligature. In using it, remember that 
it is intended to draw the cord from the bowel out of 
the external orifice, and not vice versa. This instru- 
ment has been modified and improved by Helmuth, of 
New York. (Fig. 47.) 



- 7 8 - 

Little after-treatment is required when the elastic 
ligature has been used. It will frequently be found 
that by the time the cord separates the wound has 
become superficial. 




Fig. 47.— Helmuth's Ligature-Carrier. 



Convenient Preparations for Surgeons 



WE supply Antiseptic Liquid, Tablets of Bichloride of 
Mercury, for easily preparing solutions of any desired 
strength; Labbaraque's Solution, Solution Aluminium Acetate, 
Sulphur Bricks. 

We furnish Cocaine in the following packages: Cocaine 
alkaloid, pure in crystals; Cocaine citrate, 4 per cent, solution; 
Cocaine hydrobromate, pure in crystals; Cocaine hydrobro- 
mate, 4 per cent, solution; Cocaine muriate, pure in crystals; 
Cocaine muriate, 2 per cent, solution; Cocaine muriate, 4 per 
cent, solution; Cocaine oleate, containing 5 per cent, of the 
alkaloid; Cocaine salicylate, 4 per cent, solution; Cocainized 
oil, 5 per cent. 

Cascara Cordial and Glycerin Suppositories are eligible 
and satisfactory laxatives after operations. 

Mosquera's Beef-Meal, Beef-Cacao and Beef-Jelly are 
concentrated foods, highly nutritious, perfectly palatable, and 
may be administered in a variety of forms. They constitute 
ideal foods for those enfeebled by operative procedures. 

Pepsin Cordial is an agreeable and efficient digestive and 
tonic. 

Descriptive literature of our products sent to physicians 
on request. 

PARKE, DAVIS & CO., 

DETROIT and STEW TORE. 



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more dollars, contain much irrelevant matter of no practical value to the physi- 
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Believing that short practical treatises, prepared by well known authors, con- 
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SERIES I. 



Inhalersi Inhalations and Inhalants. 

By Beverley Robinson, M. D. 
The Use of Electricity in the Removal of 
Superfluous Hair and the Treatment of 
Various Facial Blemishes. 

By Geo. Henry Fox, M. D. 
New Medications, Vol. I. 

By Dujardin-Beaumetz, M. D. 
New Medications, Vol. II. 

By Dujardin-Beaumetz, M. D. 
The Modern Treatment of Ear Diseases. 

By Samuel Sexton, M. D. 
The Modern Treatment of Eczema. 

By Henry G. Piffard, M. D. 



Antiseptic Midwifery. 

By Henry J. Garrigues, M. D. 
On the Determination of the Necessity for 
Wearing Glasses. 

By D. B. St. John Roosa, M. D. 
The Physiological, Pathological and Ther- 
apeutic Effects of Compressed Air. 

By Andrew H. Smith, M. D. 
GranularLids and ContagiousOphthalmia. 

By W. F. Mittendorf, M.D. 
Practical Bacteriology. 

By Thomas E. Satterthwaite, M.D. 
Pregnancy, Parturition, the Puerperal 
State, and their Complications. 

By Paul F. Munde, M. D. 



SERIES II. 



The Diagnosis and Treatment of Haem- 
orrhoids. 
By Chas. B. Kelsey, M. D. 

Diseases of the Heart, Vol. I. 

By Dujardin-Beaumetz, M. D. 

Diseases of the Heart, Vol. II. 
By Dujardin-Beaumetz, M. D. 

The Modern Treatment of Diarrhoea and 
Dysentery. 

By A. B. Palmer, M. D. 
Intestinal Diseases of Children, Vol. I. 

By A. Jacobi, M. D. 
Intestinal Diseases of Children, Vol. II. 

By A. Jacobi, M. D. 



The Modern Treatment of Headaches. 
By Allan McLane Hamilton, M. D. 

The Modern Treatment of Pleurisy and 
Pneumonia. 

ByG. M. Garland, M. D. 

Diseases of the Male Urethra. 

By Fessendea N. Otis, M. D. 
The Disorders of Menstruation. 

By Edward W. Jenks, M. D. 

The Infectious Diseases, Vol. I. 
By Karl Liebermeister. 

The Infectious Diseases, Vol. II. 
By Karl Liebermeister. 



SERIES III 

Abdominal Surgery. 

By Hal C. Wyman, M. D. 
Diseases of the Liver. 

By Dujardin-Beaumetz, M. D. 
Hysteria and Epilepsy. 

By J. Leonard Corning, M. D. 

Diseases of the Kidney. 

By Dujardin-Beaumetz, M. D. 

The Theory and Practice of the Ophtha 
moscope. 

By J. Herbert Claiborne, Jr., M. D. 

Modern Treatment of Bright's Disease. 
By Alfred L. Loomis, M. D. 



Clinical Lectures on Certain Diseases of 
the Nervous System. 

By Prof. J. M Charcot, M. D. 

The Radical Cure of Hernia. 

By Henrv O. Marcy, A. M., M. D., 
LL. D. 
Spinal Irritation. 

By William A. Hammond, M. D. 
Dyspepsia. 

By Frank Woodbury, M. D. 
The Treatment of the Morphia Habit. 

By Erlenmeyer. 
The Etiology, Diagnosis and Therapy of 
Tuberculosis. 

By Prof. H. von Ziemssen. 



Nervous Syphilis. 

By H. C. Wood, M, D. 

education and Culture as correlated 
the Health and Diseases of Women. 

By A. J. C. Skene, M. D. 
Diabetes. 

By A. H. Smith, M. D. 
A Treatise on Fractures. 

By Armand Despres, M. D. 
Some Major and Minor Fallacies concern 
ing Syphilis. 

By E. L. Keyes, M. D. 
Hypodermic Medication. 

By Bourneville and Bricon. 



series nr. 

Practical Points in the Management of 
Diseases of Children. 

By I. N. Love, M. D. 
Neuralgia. 

By E. P. Hurd, M. D. 
Rheumatism and Gout. 

By F. Le Roy Satterlee, M. D. 
Electricity, Its Application in Med'cme. 

By Wellington Adams, M.D. [Vol.1.] 
Electricity, Its Application In Medicine. 

By Wellington Adams, M.D. [Vol.11.] 

Auscultation and Percussion. 

By Frederick C. Shattuck, M. D. 



SERIES V. 



Taking Cold. 

By F. H. Bosworth, M. D. 

Practical Notes on Urinary Analysis. 
By William B. Canfield, M. D. 

Practical Intestinal Surgery. Vol. I. 
By F. B. Robinson, M. D. 

Practical Intestinal Surgery. Vol. II. 
By F. B. Robinson, M. D. 

Lectures on Tumors. 

By John B. Hamilton, M. D., LL. D. 

Pulmonary Consumption, a Nervous Dis- 
ease. 

By Thomas J . Mays, M . D . 



Artificial Anaesthetics and Anaesthesia^ 
By DeForest Willard, M. D., and Dr. 
Lewis H. Adler, Jr. 

Lessons in the Diagnosis and Treatment 
of Eye Diseases. 

By Casey A. Wood, M. D. 

The Modern Treatment of Hip Disease. 
By Charles F. Stillman, M. D. 

Diseases of the Bladder and Prostate. 
By Hal C. Wyman, M. D. 

Cancer. 

By Daniel Lewis, M. D. 

Insomnia and Hypnotics. 
By Germain See. 

Translated by E. P. Hurd, M. D. 



SERIES VI.* 



The Uses of Water in Modern Medicine. 
By Simon Baruch, M. D. Vol. I . 

The Uses of Water in Modern Medicine. 
By Simon Baruch, M . D . Vol. II. 

The Electro-Therapeutics of Gynaecol- 
ogy. Vol. I. 
By A. H. Goelet, M. D. 

The Electro-Therapeutics of Gynaecol- 
ogy. Vol. II. 
By A. H. Goelet, M. D. 

Cerebral Meningitis. 

By Martin W. Barr, M. D. 

Contributions of Physicians to English 
and American Literature. 
By Robert C. Kenner, M. D. 



Gonorrhoea and Its THifetment. 
By G. Frank LydstonrM. D. 

Acne and Alopecia. 

By L. Duncan Bulkley, M. D. 

Fissure of the Anus and Fistula in Ano. 
By Dr. Lewis H. Adler, Jr. 

Cholera. 

By G. Archie Stockwell, M.D., F.Z.S. 

Massage and the Swedish Movement 
Cure. 

By Baron Nils Posse. 

Sexual Weakness and Impotence. 
By Edward Martin, M. D. 



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